LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

February 03, 2014

Pulling the Plug on DNR Orders

Recently, a friend commented that she was not sure whether or not to agree to a “DNR order” for her 90 year-old mother. Her mother has dementia and lives in a nursing home; she is her mom’s health care proxy. Complicating her decision was the knowledge that her mother had chosen a DNR status when she was cognitively intact, but then reversed her decision at the time of acute illness, believing that “DNR” meant she would not receive vigorous treatment for medical problems such as an infection or congestive heart failure. My friend told me she believed the purpose of a DNR order was to avoid a protracted, painful death and that DNR was synonymous with comfort care. The truth is that DNR means “do not perform CPR”—the “R” in DNR refers to resuscitation, which is shorthand for “cardiopulmonary resuscitation.” CPR is a procedure intended to counteract a cardiac arrest—the sudden cessation of the heart beat and of breathing. CPR involves administering electric shocks and, more often than not, providing artificial respiration, usually through a breathing machine (ventilator). In principle, DNR or, as it should more properly be called, since there is only a small chance that CPR will actually succeed in restoring cardiac function, DNAR (do not attempt resuscitation) refers only to what will or will not be done if the heart stops beating and breathing ceases. It has no implication for any other form of treatment. But nearly 40 years after the first DNR orders were written in hospitals, confusion about their meaning persists.It’s not just patients and families who are confused: physicians are confused as well. I just read Sheri Fink’s book, Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, in which the triage decisions made during Hurricane Katrina included placing patients with a DNR order at the bottom of the evacuation list. Reportedly, physicians at Memorial thought that patients could have a DNR order only if they were terminally ill, which is false: a patient can elect a DNR order whenever the burdens of CPR are felt to outweigh the benefits, or if CPR is thought to be extremely unlikely to succeed--regardless of the underlying medical condition. When it looked as though not all of Memorial Hospital’s patients were going to be evacuated, it was the DNR cases who were to be left behind, sedated so as to ease their allegedly inevitable and imminent deaths.And it’s not just in the midst of a disaster that physicians mistake “DNR” for “Do Not Treat.” Study after study has shown that physicians say they would not administer a whole variety of treatments to patients who are DNR. One representative study of 241 physicians found that they were far less likely to agree to transfer a patient to the intensive care unit or even to perform simple tests such as drawing blood. Most recently, physicians and nurses caring for pediatric patients also told interviewers that in practice, DNR means far more than just do not perform CPR. In this survey of 107 pediatricians and 159 pediatric nurses in a hospital setting, 67% believed a DNR order only applies to what to do after a cardiac arrest—but 33% said it implied other limitations. And 52% said that once a DNR order is in place, a whole host of diagnostic and therapeutic interventions should be withdrawn, over and beyond CPR, and a small but disturbing minority, 6%, said that a DNR order means that comfort measures only are to be provided. Why, so many years after the concept of DNR was introduced, does it remain so problematic? I think both patients and physicians implicitly recognize that asking about CPR is simply the wrong question—that’s why they assume DNR refers to so much more than what doctors should do if the heart stops beating. The right question has to do with figuring out what it is that medical treatment is supposed to achieve. Is it prolonging life at any cost? Is it providing comfort and dignity? Or is it something in between, preserving those basic functions such as walking and talking and seeing and hearing that a person values most? Only after defining the overall goal of care does it make sense to focus on delineating the specific treatments that are most consistent with achieving those goals. An enormous amount of energy and ink have been squandered on debating about cardiopulmonary resuscitation, one of many possible medical treatments that seeks to achieve one of several possible medical goals. Maybe it’s time to pull the plug on DNR orders, banning them unless there is first a conversation about the overall direction of medical care. One approach to doing exactly this is POLST, Physician Orders for Life-Sustaining Treatment or, as it is called in some states, Medical Orders for the Scope of Treatment. This is a medical order, just like an order a doctor writes in a hospital for antibiotics or for blood tests; it is not just a wish statement about future care. It includes a list of specific interventions that a prospective patient has agreed are undesirable under any circumstances, and often includes CPR along with other treatments such as dialysis or artificial nutrition. But before a physician and patient agree on such an order, a conversation is supposed to take place about the goals of medical care. The problem is that it's far from clear that patients and doctors are having those discussions. They may simply be jumping to the final step, writing that order. POLST is a promising development, but only if at least as much time is spent on talking about the big picture as on its implementation.